THE ISSUES

Children with sensory-based feeding difficulties
frequently limit the types of food and liquid that they
are willing to eat. Problems with sensory regulation and
sensory defensiveness lead toward many uncomfortable
surprises that become associated with food and mealtimes.

THE PRINCIPLES

Children need to learn about new foods in an
unthreatening way. They need a great deal of exposure to
a food before they will consider tasting it or eating it.
Mealtimes frequently are associated with expectations for
eating and drinking. Many children are on guard and spend
a great deal of energy protecting themselves from new
sensory experiences that feel dangerous. Comfort and
safety are the most important aspects of the mealtime.
When children feel safe and comfortable, they are more
willing to risk and participate in new experiences.

Feelings of comfort and safety are based upon adequate
sensory processing and gastrointestinal comfort. When
these two areas are not functioning efficiently, children
will spend more energy protecting themselves than
learning about new foods. They will limit their food
choices to a narrow group of familiar foods that they
have experienced as safe. Mealtime programs
that are successful incorporate overall strategies to
improve sensory processing and integration and reduce
gastrointestinal reflux and discomfort.

Adequate nutrition comes from eating a wide variety of
foods. Mealtime programs that place a stronger focus on
expanding dietary choices than on increasing dietary
amount will have greater long-range success.

THE GUIDELINES

Incorporate Strategies for Normalizing Sensory
Processing Before and During Encounters with Food

Activities that provide specific types of sensory
input can support sensory organization and reduce sensory
defensiveness. This includes movement through space or
vestibular input. Slow swinging, for example, can be used
as a transition between more active activities, prior to
mealtimes or activities like tooth brushing to help
prevent sensory defensiveness and overload, and as a
quiet, organizing activity when a child is listening to a
story or receiving a tube feeding.

Jumping and bouncing also provide vestibular input. In
addition, they provide the sensory input into the joints
that is called proprioceptive stimulation. Proprioceptive
input is organizing for many children, and can help
reduce sensory defensiveness when provided before food
exploration and mealtimes. It also helps children who
have low tone and reduced postural stability gain better
steadiness for more controlled movements. Other
activities that provide strong input into the joints and
muscles include pushing (the swing, a wheelbarrow, or
stroller), carrying (boxes, pile of laundry, pillows),
somersaults, hanging upside down, climbing stairs or
hills, and marching.

Firm hugs and hiding under piles of pillows provides
the sensory input to the skin known as deep
touch-pressure input. Roughhousing, rolling up in a
blanket, and sleeping under piles of covers also provide
this kind of sensory stimulation.

Specific types of sound and music are also highly
organizing for the nervous system. The use of music
containing specific binaural beats known as Hemi-Sync has
been particularly helpful for children with sensory
processing difficulties. When this type of music is used
in the background during sensory exploration and
mealtimes, many children experience more focused
attention, reduced sensory defensiveness, and greater
openness to new experiences.

Observe the child very carefully when introducing
these types of stimulation. Sensory stimulation should
never be imposed on a child. Some children become more
disorganized with vestibular input and do not like
swinging and bouncing. Others lack the overall motor
control to engage in self-generated activities that
provide strong input to the joints and muscles. Still
others may find background music distracting or
disorienting. Observe the types of activities that the
child seeks and enjoys. Expand ways in which the child
can receive the types of sensory input associated with
these activities. Introduce sensory activities at
specific times during the day as a sensory diet that can
help the child attain and maintain greater sensory
comfort throughout the day. When the sensory system is
functioning more normally, children will be more open to
making new discoveries about the sensations that
accompany eating and drinking.

Build on What the Child Knows and
Accepts

Make a list of the foods and liquids that the child
currently accepts and likes. Organize these by sensory
properties such as taste, texture, color, or smell. For
example, does the child eat mostly foods that are crisp
or crunchy? Foods that have a strong taste? Foods that
are bland? Foods that are sweet? Foods that are soft and
smooth? Foods with similar colors?

Make a list of other foods in the same categories. For
example, a child who eats potato chips and pretzels may
accept other crisp, salty foods more easily than foods
that are soft or bland. Corn chips and crackers could be
introduced to the diet. Bread could be introduced as
toast, or sandwiches could be created on crackers rather
than soft bread.

A child who eats soft smooth foods such as pureed
applesauce or bananas may accept another white fruit such
as pears or a mixed fruit such as bananas and pineapple
more easily than green beans. In this example the pears
are in the white, sweet fruit group. The primary change
is a slight difference in the sweet taste. Green beans
are very different in both color and taste and may
represent too drastic a change for the very sensitive or
suspicious child.

Create new combinations from two foods that the child
usually likes and accepts. For example, a child who likes
popcorn, corn chips, and cheese may accept popcorn with
melted cheese or Nachos (melted cheese over large corn
chips). The child who likes the taste of a smooth mango
puree and a peach puree, may enjoy a blend of mango and
peach.

Make Very Small Changes as New Foods
are Introduced

Small, gradual changes are always easier to accept
than large or sudden changes. We experience this
guideline in all areas of our lives. When changes in the
sensory properties of food (i.e. color, taste, texture,
smell, and temperature) are made too rapidly, many
children just say NO! To prevent this from
happening and support the child's success, make very tiny
changes in the new foods that you offer.

One of the simplest changes is to introduce a new
brand or variety of a food that the child accepts. There
are very slight differences in taste or texture in
different brands. These may be very subtle, or very
noticeable to a specific child.

Introduce different types of food that the child
accepts. Yellow cheese could be Mild Cheddar, Medium
Cheddar, Sharp Cheddar, Colby, or Longhorn. White cheese
could be Swiss, Gruyere, or Mozzarella. Apples come in
sweet, tart, firm, and soft variations. Applesauce comes
in sweetened, unsweetened and cinnamon applesauce.
Pretzels can be long and thin, short and fat, or round.

Make bridges toward totally new foods based on taste,
texture, and color. For example, a yellow apple and a
yellow pear have many similarities but a few important
differences in taste and texture. A child who eats apples
may have an easier time moving to pears than to
strawberries. A child who eats strawberry yogurt may
transition easily to raspberry yogurt.

Build Familiarity with New Sensations
and New Foods through Play

Children learn to make friends with new foods by
playing with them. When they stir, pat, smear, pour, and
make designs with an unfamiliar food, they experience the
sensory qualities of that food. What color is it? What
does it smell like? What does it feel like on the hands?
Is it smooth or does it have some texture? Is it wet or
dry? They may add other sensations to their play as they
lick a finger or take a small taste from the spoon used
for stirring. Gradually they develop the comfort to
explore the food with the mouth as they begin to eat
small amounts.

When food play is separate from the child's meal,
children know that they are not expected to taste or eat
the food. This gives them confidence and greater
willingness to experience the food in other ways. Food
play can begin with pretend foods such as a soft plastic
apple or plastic slices of bread and cheese. The child
can explore these foods with the lips and tongue or
pretend to feed them to a doll or stuffed animal. A real
apple, bread, or cheese can be introduced into the play
as the child becomes more comfortable and accepting of
real food. Strips or small cubes of cheese can become the
eyes, nose, mouth, and hair on an apple face or on a
piece of bread. A boat could be hollowed out of a
cucumber or zucchini with an older child. The emphasis is
entirely on the familiarization that comes through play.
If adults try to convince children to take a bite of the
food, they may become suspicious that the adult has an
ulterior motive. They begin to perceive the situation as
another trick to get them to eat rather than enjoyable
food exploration.

Some children need the opportunity to stir and mix
food and smear it on the highchair tray as a preparation
for taking a spoonful. Small amounts of food play at
mealtimes are very appropriate for young children who
missed this stage of development when they were infants.
Once the child has become familiar with the food through
play, introduce it as part of the meal.

Help Children Feel Physically and
Emotionally Safe with Textured Foods

Lumpy foods or solid foods that must be chewed can be
very frightening to children. As they become more afraid
and feel pressure from adults, they increase tension in
their face and mouth. They clench the jaw or pull back
the tongue. They may open the mouth a tiny amount. They
may freeze and stop moving the tongue as soon as they
feel the food touch it. The tension and lack of mouth
movement increases the child's sensory discomfort. Pieces
of food may sit on the back of the tongue and trigger a
gag. The child panics and decides that this type of food
is dangerous and must be avoided in the future.

Typically developing infants spend many months
exploring toys with the mouth. They sense the toy's
firmness by repeatedly biting into it. They feel shape
and size with the lips and tongue. As they learn to push
the toy around in the mouth with the tongue, they
discriminate the lumps and bumps of surface texture. As
they do this, they feel very safe because the lumps and
bumps don't come off. They don't have to be manipulated
in the mouth and swallowed. When they encounter lumps in
food or bite off a piece of cookie or cheese, they have
had experience with textures in toys so they are not
afraid. They know they can handle the new experience with
foods.

It is important for children with feeding difficulties
to have experience exploring toys or objects with the
mouth. Many children miss this stage of infant
development. They may avoid mouthing their hands or toys
because they are uncomfortable with mouth stimulation.
Or, they may have engaged in a more generalized random
mouthing that did not include exploration with greater
sensory awareness.

Children need to know that they can get pieces of food
out of their mouths. Adults can help them use their
fingers to remove a piece of food, learn to spit the food
into a bowl with good lip and tongue control, and gather
small pieces of food together for swallowing by using a
smooth food that binds or sticks the pieces together.
Smooth applesauce could be paired with chunky applesauce.
Blenderized spaghetti sauce could be use to bind together
pieces of pasta that are stuck on the tongue. Some
children learn to clear their mouths by taking small
drinks between bites.

Many children can learn to bite off a piece of food
and spit it out immediately. As this becomes comfortable,
they may progress to holding the food in the mouth or
moving it around the mouth before spitting it out.
Gradually they will learn to chew it briefly without
swallowing and then swallow small amounts as they chew.
Through confidence, comfort, and experience they master
chewing and swallowing foods easily and independently.

When children know that they can get the food out of
the mouth when they need to, they are much more likely to
put it into the mouth. If they feel threatened or unsafe,
they will fight any attempt to put the spoon or food in
the mouth.

Build Acceptance through Gradual
Repeated Exposure to the Food

All children need repeated exposure to a new food
before they are comfortable eating it. Studies have shown
that children without a history of feeding difficulties
are more likely to eat new foods that they have seen or
played with many times. They see the food on someone
else's plate or in a serving bowl. They smell it as it is
cooking and while they are sitting at the table. They may
play with macaroni and cheese on the high chair tray or
chase pieces of carrot around the plate with a finger
long before they would consider putting the strange food
in their mouth.

Some children need to begin by listening to a story or
looking at a picture book about the food. Others may have
trouble being in the same room with the food. They may
have developed such strongly aversive responses that they
will scream or vomit as soon as they smell or see the
food. It is important to identify the type of
relationship with the new food that feels safe to the
child and slowly increase the child's involvement with
the food. Some children will become upset and want to
leave the table if a new food is placed in front of them.
If the food is on the other side of the table, it is
okay. Gradually the food can be moved closer and closer
until it is in a dish in front of the child. As this is
accepted, the food can be placed on the child' plate.
This progression is usually more successful if the food
has been included in food play that is separate from the
child's mealtime. Introduce a new food at the meal after
the child has explored aspects of it during the food play
and exploration. For example, cut-up pears at the meal
could follow play with boats made of pear halves floated
in the bath tub.

Many adults will offer the child a new food once or
twice. When the child refuses to eat it, the food is
placed on the does-not-like-it list and is never offered
again. Since this happens when most new foods are
presented the list of possible foods shrinks, and the
child and parent settle with a diet of 4 or 5 foods that
are acceptable. When food is offered many times without
pressure to eat it, the child becomes familiar with its
sight, smell, feel and taste. Curiosity and hunger may
encourage the child to take a few bites and eventually
incorporate the food into an expanded diet.

Build Interest and Involvement with
Food and Mealtime Preparation

Young children love to imitate their parents as they
wash the table, vacuum the floor, stir a cake mix or
stack the laundry. When children are cautious or
suspicious about new foods, they may avoid the kitchen
and miss out on many aspects of food and mealtime
preparation. This may happen because cooking smells are
offensive or children are afraid that adults will push
them into tasting or eating the food.

Even very young children can carry their plate or bowl
to the table when it is time for lunch or take the bowl
to the kitchen sink or dishwasher when they have finished
eating. This helps them understand where the food came
from and that meals have a clear beginning and end. At
the beginning of the meal, the child can scoop the food
from a serving dish or baby food jar into his own bowl.
Older children can help cook the meal for the family or
plant vegetables in the garden or grow herbs in a small
pot in the window. Caring for the plants and watching the
vegetable grow create a stronger interest in cooking and
eating the food.

Offer Foods with High Nutritional
Value

Children with sensory-based feeding issues are often
picky eaters who will eat only a small number of foods.
They may become stuck in eating foods with similar
sensory or nutritional characteristics. For example, one
child might drink milk, and eat yogurt and cheese,
limiting intake to dairy products. Another child might
live on cookies, bread, and white rice, a very limited
refined carbohydrate diet. Fruits and vegetables are
often missing from children's diets. Because many
children like sweet tastes, parents will offer them candy
and sweet deserts to entice the child to eat or learn to
chew. Because children with sensory issues have
difficulty with change, they can get addicted easily to
these super-sweet foods and refuse more nutritious foods.
If the child prefers sweeter foods, begin with a
vegetable like carrots or sweet potato or add maple syrup
to some vegetables, fruits or cereals. This offers a less
intense sweetener that provides both nutrients and high
quality calories. Some children like the intense tastes
provided by carbonated beverages. Instead of giving the
child soda pop, mix a favorite fruit juice with
carbonated mineral water. Pieces of vegetable or meat can
be dipped into spicy condiments such as barbecue sauce,
salad dressing, or salsa. Children can chew on crunchy
carrot sticks or pickles at the beginning of the meal to
wake up the mouth. Herbs and spices can be added to foods
to increase the intensity of their sensory input.
Children need dietary variety to get the calories and
nutrients required for growth. Nutritional supplements
can be added to the diet with the guidance of a qualified
dietitian or physician. High quality food supplements,
such as a dehydrated fruit and vegetable powder, can be
blended with foods the child accepts.